FESTIVAL & EVENTS ONTARIO - LIABILITY INSURANCE APPLICATION

General Information:

1. Name of Insured: Lynden Canada Day Committee - City of Hamilton

2. Mailing Address: PO Box 212, Lynden, ON, L0R 1T0

3. Applicant is: X Non-Profit Association ? Corporation ? Partnership ? Other:

4. Name of Festival/Event: Lynden Canada Day Festival Web Site: www.lynden-on.ca/canadaday

5. Location(s) of Event: Lynden Community Park

6. Festival/ Event Venue is: ? Owned X Rented ? Leased

7. Description of Event: Morning Parade, Afternoon Car Show, Activities and Fireworks at Dusk

8. Does this organization engage in any other business operations under the Name of Insured? ? Yes X No

If “Yes”, please describe:

9. Has this event been held by Applicant in the past? X Yes ? No Number of Years: 16

10. Any losses in the past five years? ? Yes X No If Yes, Please attach a complete Five Year Loss History

11. Has any form of Insurance ever been cancelled/declined? ? Yes X No If Yes, provide details:

12. Desired Limit of Liability: ? $1,000,000 X $2,000,000 ? $5,000,000

13. Effective Date: June 30, 2011 Expiry Date: July 2, 2011 (If more than one location and/or date, please attach a schedule of all locations and dates)

Operating Information:

1. Venue Capacity: 4,000 Estimated Attendance: Per Day: 2,000 Total: 2,000

2. Do you have a written Evacuation Plan due to Fire, Severe Weather or other Emergency? ? Yes X No If Yes, attach a copy

2. Name(s) of Performers/Bands & Type of Entertainment, if any: “Corky” the clown, “Two of a Kind” - Musicians

3. Are alcoholic beverages offered at your Festival/Event at any time? ? Yes X No

If Yes, is Certificate of Insurance provided for Host Liquor Liability, naming you as Additional Insured? ? Yes ? No If No, please attach Supplemental Liquor Liability App

Limit: Insurer:

4. Do you secure proof of Insurance from Vendors, Exhibitors, Independent Contractors and Performers? ? Yes X No

If No, who does not provide a Certificate of Insurance naming you as Additional Insured?Clown, musician

5. Who is responsible for providing Security for the Festival or Event? Lynden Canada Day Committee

If Applicant, is Security provided by employees, police or an outside security firm? Volunteers

If Other than Applicant, is a Certificate of Insurance provided naming you as an Additional Insured? ? Yes X No

6. Does the Insured require signed waiver/release forms for any activity? ? Yes X No If Yes, Please attach acopy

If Yes, what activity:

7. Details of all Scheduled Events: (attach a separate sheet if needed)

DateMain Activity

EstimatedAttendance Other Activities

Total Attendance

July 1, 2011 Canada Day Festival 2,000 0 2,000

8. Estimated Gross Receipts - Total: $23,000.00 Estimated Gross Receipts - Food: $300.00

Estimated Gross Receipts – Liquor: 0 9. Number of Employees: 0 Number of Volunteers: 50

10. Is First Aid provided? X Yes ? No If Yes, describe: Right Reaction -Canadian Red Cross Provider 11. Is any Shuttle Service provided? ? Yes X No If Yes describe:

12. Does the Event involve a Parade, Motorsports (e.g. Tractor Pull, Demo Derby, Mud Bog, Race) Horse Show/Racing,Rodeo, or Petting Zoo? X Yes ? No If Yes List each activity:

Parade If Event involves a Parade with more than 10,000 attendees, please attach Supplementary Parade Application

13. Will services be performed on event attendees (e.g. tattoo, face painting, massage) or will attendees be involved in any demonstrations, performances etc? X Yes ? No If Yes Describe: Children’s Face Painting

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14. Does the Event involve Fireworks? X Yes ? No If Yes are they done by a Licensed Pyrotechnician? X Yes ? No

If Event involves Fireworks, is a Certificate of Insurance provided naming you as Additional Insured? ? Yes X No

Limit: Insurer:

15. Is Applicant providing any Overnight Camping Facilities or other accommodations? ? Yes X No

If Yes, how many spaces/rooms?

Is 24-hour security maintained? ? Yes ? No

16. Does the Event involve any Animal Exposures? X Yes ? No

If Yes, provide full details of exposure and Applicant’s responsibilities:Horses in Parade, Cow Patty Bingo

If Yes, is a Certificate of Insurance provided naming you as Additional Insured? ? Yes X No

Limit: Insurer:

17. List any Temporary Structures used during Event (e.g. Stage, Lighting, Tents, etc.) Small Canapies 10' x 12'

Who is responsible for set up of same, Applicant or Other (name)? Applicant

If Other than Applicant, is Certificate of Insurance provided? ? Yes X No

Limit: Insurer:

18. Does the Festival/Event involve Amusement Rides, Climbing Walls, Inflatables or other Amusement Devices? ? Yes X No If Yes, name and describe each ride/device, and indicate who owns each one:

If Yes, who is responsible for set up of same, Applicant or Other (name)?

If Other than Applicant, is Certificate of Insurance provided naming you as Additional Insured? ? Yes ? No

Limit: Insurer:

19. Do you assume liability of others by contract? X Yes ? No If Yes, attach a copy and explanation of contract

City of Hamilton who we rent the park from

Please list the organizations that require a Certificate of Insurance from you (As they are to appear on the policy)NAME ADDRESS RELATIONSHIP TO YOU*

1. City of Hamilton 77 James Street N.

Hamilton, ON L8R 2K3

None

2.

* If the additional insured is an owner, manager or lessor of the premises, please indicate the name and street address of thepremises leased or rented to you by the designated additional insured, as respects to your activity or operation.

Please attach the following information to this application:a. Loss Runs for the previous five yearsb. Diagram of Festival/Event layout and buildings if availablec. Copy of Brochure or other Advertising/Promotional Material for this Eventd. Current Schedule of Eventse. Copy of all Contracts and Waiversf. Supplementary Liquor Application, if applicableg. Supplementary Parade Application, if applicableh. Written Evacuation Plan, if applicablei. Camping Rules & Regulations, if applicable

VERY IMPORTANT

THIS APPLICATION IS SUBMITTED WITH THE FOLLOWING SPECIFIC UNDERSTANDING:

(a) Applicant warrants and represents that the above answers and statements are in all respects true and material tothe issuance of an Insurance Policy and that Applicant has not omitted, suppressed or misstated any facts.

(b) The signing and filing of this Application does not bind the Applicant or the Company and no Insurance shall bedeemed effective unless and until a written binder or Policy of Insurance is issued by the Company in responsehereto.

(c) All exclusions in the Policy apply regardless of any answers or statements in this Application.

(d) Applicant understands that the Deductible under any Policy to be issued in response hereto shall include bothloss payment and claim expenses as defined in the Policy.

(e) If any of the above questions have been answered fraudulently, or in such a way as to conceal or misrepresentany material fact or circumstance concerning this Insurance or the subject thereof, the entire Policy shall bevoid.

Applicant Signature: Date: Feb. 22, 2011

Title: Permits Chair Phone: 519-647-2795

Activity Schedule and Admission

 

11:00 a.m.Parade Lynden Rd /

Governors Rd

NoonAfternoon Activities

Lions Park Donations gratefullyaccepted at the gate

? Opening Ceremonies ? Great Food! ? Citizen of the Year Presentation ? Buttercup - Face Painting ? Children's "Pick a Chick"

   Free Prize Giveaway !! ? Adult Instant Win Table

Many Excellent Prizes ? Antique Car / Tractor Show ? Chill Zone ( 12+ ) ? Pedal Tractor Pull ? Turkey Rhubarb ? Cow Pattie Bingo ? Float and Costume Awards ? Antique Vehicle Awards

6:30 p.m.Evening Entertainment

Lions Park Donations gratefully accepted at the gate

? Buttercup - Face Painting ? Corky the Clown

    Balloon Artists for the Kids ? Pedal Tractor Pull ? Baby Show ( < 24 months ) ? Rumbleshack

Dusk

Lions Park

Page 1 of 2Lynden Canada Day Celebration - Activity Schedule and Admission

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FIREWORKS ! ! ! Donations gratefully accepted at the gate

Page 2 of 2Lynden Canada Day Celebration - Activity Schedule and Admission

2/22/2011http://www.lynden-on.ca/canadaday/schedule.html